Clara Moniatis
PFD Report
All Responded
Ref: 2020-0221
All 1 response received
· Deadline: 18 Dec 2020
Coroner's Concerns (AI summary)
Concerns included lengthy waiting times between chest x-rays and image review, and the absence of a system ensuring prompt clinical review after a PEWS alert.
View full coroner's concerns
1. The matter of waiting times from chest x-ray to the review of the imaging
2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review
2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review
Responses
Noted
The Trust states that early senior review of deteriorating patients is critically important and they have shared learning widely among clinical staff; however, they believe that nothing could have prevented the patient's outcome. (AI summary)
The Trust states that early senior review of deteriorating patients is critically important and they have shared learning widely among clinical staff; however, they believe that nothing could have prevented the patient's outcome. (AI summary)
View full response
Dear Ms Beasley-Murray RE: Regulation 28: Report to Prevent Future Deaths
I write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding the care of Clara Moniatis. Clara, a 5 month old child, was bought to the Whipps Cross Hospital (WCH) Emergency Department (ED) by her parents with worsening symptoms of possible tonsillitis. Having been clinically stable, Clara deteriorated rapidly after 5 hours in the department and arrested, resuscitation was unsuccessful. Post mortem examination identified previously undiagnosed dilated cardiomyopathy.
The matters of concern raised in the Regulation 28 notice were:
1. The matter of waiting times from chest x-ray to the review of the imaging
2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review
We have previously noted that the documented timings of x-ray review represent a maximum time, as notes are often made in retrospect within a busy emergency department.
Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff.
I write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding the care of Clara Moniatis. Clara, a 5 month old child, was bought to the Whipps Cross Hospital (WCH) Emergency Department (ED) by her parents with worsening symptoms of possible tonsillitis. Having been clinically stable, Clara deteriorated rapidly after 5 hours in the department and arrested, resuscitation was unsuccessful. Post mortem examination identified previously undiagnosed dilated cardiomyopathy.
The matters of concern raised in the Regulation 28 notice were:
1. The matter of waiting times from chest x-ray to the review of the imaging
2. The matter of the need for a system whereby a PEWS alert leads to a prompt clinical review
We have previously noted that the documented timings of x-ray review represent a maximum time, as notes are often made in retrospect within a busy emergency department.
Following a thorough review of our own investigation findings and the views of the Coroner’s expert witness, and taking into account that Clara was seen by a senior specialist doctor within 20 minutes of her PEWS increase, we believe we could have done nothing which would have prevented Clara’s sad outcome. However, this has reaffirmed the critical importance of early senior review of deteriorating patients, following national guidelines on the escalation protocol for PEWS, and we have shared the learning widely among our clinical staff.
Sent To
- Barts and Whipps Trust
Response Status
Linked responses
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56-Day Deadline
18 Dec 2020
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 15 May 2019 I commenced an investigation into the death of Clara Iris Moniatis.. The investigation concluded at the end of the inquest on 7 October 2020. The conclusion of the inquest was:-
Clara Iris Moniatis had been unwell for some days and on the morning of 5 May 2019 she was taken to the Emergency Department of Whipps Cross Hospital. Despite medical treatment, she died there at 18.56pm that evening. She died of Natural Causes.
Clara Iris Moniatis had been unwell for some days and on the morning of 5 May 2019 she was taken to the Emergency Department of Whipps Cross Hospital. Despite medical treatment, she died there at 18.56pm that evening. She died of Natural Causes.
Circumstances of the Death
The cause of death was 1a) dilated cardiomyopathy. This condition had been previously undiagnosed
Please see above
Please see above
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.